All study procedures were approved by the Johns Hopkins School of Medicine Institutional Review Board (IRB00241244). Oral informed consent was audio-recorded and documented in study folders prior to conducting baseline study visits. Participants were given study ID numbers, and identifiable information (ie, names and data) was stored on private, password-protected servers. Participants were provided a US $50 electronic Amazon gift card for the baseline visit.

POSSIBLE was a single-group, 2 session pilot intervention conducted between 2019 and 2021 that was refined using the ADAPT-ITT (Assessment, Decision, Administration, Production, Topical Experts, Integration, Training, and Testing) model [37]. Formative research was conducted to refine key aspects of the intervention approach such as the usefulness of the app-based diary and PCA characteristics among Black sexual minority men of different age groups [6].

POSSIBLE incorporated a PCA who was matched with participants’ key demographic and cultural characteristics as guided by theory, previous studies, and formative research identifying preferences among Black sexual minority men [6,38]. Specifically, studies suggested that the PCA should have similar experiences as Black sexual minority men (eg, navigating interactions with romantic or sexual partners, clinicians, and health insurance) and be a “future self” to whom they could aspire [6,38]. Therefore, the principal investigator (PI to DTD), used Descovy for PrEP and served the intervention as the PCA. Further details regarding the experience and dual role of the PI serving as a PrEP-using PCA have been published in an autoethnography [17].

PrEPme was designed for Maryland users to obtain statewide PrEP service information and navigation support from an app-based community health worker (CHW) [25]. PrEPme also allows users to self-monitor sexual risk behaviors, view a graph of sexual risk behaviors by week and month, and chat with the CHW in the app to obtain PrEP service information [6].

A CHW supervised by a nurse case manager within the Center for Infectious Disease and Nursing Innovation at the Johns Hopkins School of Nursing (previously known as the REACH Initiative) provided navigation services including reviewing eligibility for or access to medical insurance, identifying preferred clinic locations, and arranging appointment and scheduling activities. Occasionally, the PCA referred participants or helped schedule appointments at PrEP service organizations for individuals who wanted to avoid interfacing with additional staff associated with a medical research institution.

Participants were recruited using a combination of active and passive strategies [39,41] in Baltimore, Maryland, and were eligible based upon the following self-reported criteria: Black or African American race, identifying as a cisgender person, being 18 years and older of age, same-sex attraction to men, HIV-negative, and having oral or anal sex with ≥1 male partner in the previous 6 months.

This concept was assessed using the 8-item PRH scale from Napper et al [42] before and after the baseline visit. Sample questions included items assessing concerns about HIV and perceived likelihoods of infection. Total possible scores ranged from 10 to 40, higher scores indicate greater PRH. The scale was found to be reliable (8 items, α=.78).

Paired 1-tailed t tests were used to examine changes in PRH after the end of the study. Descriptive statistics were used to explore the proportion of participants who were referred to services and scheduled a PrEP appointment after baseline.

This study explored the feasibility and preliminary effectiveness of POSSIBLE, a multicomponent intervention using a PCA and mobile app–based diary to improve PRH among Black sexual minority men. Given the high retention rate, POSSIBLE may be a feasible multicomponent strategy to implement among Black sexual minority men. We found improvements in PRH after baseline sessions [40]. However, we observed no statistically significant improvement in PRH after intervention from baseline to month 1.

We observed relatively low PRH scores at baseline and month 1 follow-up. Analyses showed that the PCA increased baseline PRH scores [40]. The effects of the intervention may have been maximized in the baseline session such that the addition of the app for reflexivity could not increase scores from baseline to month 1. Other studies have found that competing survival priorities supersede HIV-related concerns in the lives of Black sexual minority men. The shift from HIV as a “death sentence” in the early days of the epidemic to its positioning as a manageable chronic health condition could be a key reason for low PRH and for why perceived risk did not change from baseline to month 1. Black sexual minority men may also consider their current behaviors relatively safer than their past or their peers’ behaviors as found in previous studies [6,10]. Some may appraise their vulnerability based upon their most recent behaviors, which may not have involved condomless sex or drug use in the month of the intervention, which was conducted partly during the height of the global COVID-19 pandemic.

We also observed relatively low use of the app-based diary in PrEPme. Mobile health interventions have been successful largely because of the convenience of the intervention within smartphone apps. However, PrEPme seemingly did not add value to the PCA intervention component. Studies suggest that aspects such as aesthetics, social networking ability, and gamification impact Black sexual minority men’s use of app-based HIV prevention apps [24,43]. The self-monitoring feature of the app-based diary could be refined for gamification and cultural responsiveness. PrEPme also did not maximize the power of health communication to tailor messaging. However, we are unable to identify reasons for nonuse. Qualitative insights or participant feedback could help in identifying barriers to app use. In light of previous analyses showing baseline effects on PRH [40], adding the mobile app–based diary may not be necessary in the presence of an effective PCA.

The intervention did observe relatively high proportions of willingness to accept PrEP referral and initiation, which could be attributed to the interpersonal dynamics between participants and the PCA [17]. Studies consistently show that peers and social networks are important, trusted sources of health information and effective interventionists among marginalized communities, including Black sexual minority men [16,38,44,45]. Studies also show that Black sexual minority men are more willing to initiate PrEP if their peers are using it. The usefulness of communicating with a PCA may not have been outweighed by the convenience of technology. PRH may not necessarily be the primary motivation for PrEP referral willingness or initiation among Black sexual minority men.

Despite the feasibility of this intervention, using a PCA to catalyze PRH and PrEP initiation among Black sexual minority men is not without challenges. DTD described internal conflicts regarding honoring participants’ disinterest in PrEP versus professional goals to increase uptake for HIV prevention in an autoethnography [17]. Additionally, managing discussions regarding side effects with Black sexual minority men whose health histories the PI or PCA was unfamiliar with or unqualified to discuss is important to consider in this peer-based approach. Concerns that being a PCA could overshadow professionalism as a researcher and health care professional were also salient [17]. PCAs should be trained to manage insider-outsider dynamics as an interventionist among Black sexual minority men, engage in active listening, and communicate with care [17,46]. Some qualities may not be able to be provided in training such as the shared social experiences and vulnerabilities of being Black sexual minority men.

Study limitations include insufficient sample size to detect effect sizes. Causal inferences cannot be drawn, and effectiveness cannot be established with a pre-post single-group design. It is also possible that unstudied external factors could have produced the changes observed. All data were self-reported. A larger trial is needed to definitively establish the effects of the intervention, including biological confirmation of PrEP use beyond self-report.

Future research should test a statistically powered peer-based approach on PrEP initiation among Black sexual minority men. Psychometric tests should also be conducted to identify culturally relevant concepts of HIV risk and PrEP motivation for Black sexual minority men. Qualitative research should also clarify how app-based sexual risk diaries have unintended consequences of triggering self-stigma and shame versus informed decision-making [6]. Targeted studies among young Black sexual minority men younger than 35 years of age should be conducted, given their high HIV incidence and low PrEP uptake. Studies show age cohort differences regarding the needs and vulnerabilities among Black sexual minority men such that peers may be a more effective behavior change mechanism for younger men [33,47,48]. If effectively implemented, the person-centered approach of a PrEP-using PCA approach could lead to substantial community-level impact for Black sexual minority men because their needs are not the same.